Today the independent judicial review into the junior doctor contract imposition legality, put forth by the five junior doctors who make up Justice 4 Health, closed.

Justice Greene found in favour of the government, upholding their peculiar defence that Jeremy Hunt never actually imposed a contract, leaving it up to local hospitals to decide if they want the new contract or not. This, despite the fact that Jeremy Hunt has repeatedly hit the ‘nuclear button’ of imposition in TV interviews, parliament and speeches. Here is a quick video with some obvious examples;

As ludicrous as it seems, legally we have told all of this was an ‘irrelevance’ and although the judge suggested Jeremy Hunt could’ve been less ‘ambiguous’, the High Court rules that the contract was never imposed in the first place. News to 54,000 doctors, and no doubt many patients who were adversely affected by strike action against imposition. This final legal clarity prompted the question; if Jeremy isn’t imposing, who is? Well it would seem hospital trusts are imposing , and therefore can we now negotiate directly with them?

NHS Providers quickly tweeted to crush this speculation – they want a nationally agreed contract, and suggest there will be no local negotiations.

This of course follows in the same week that the BMA JDC have decided to suspend further strikes, and instead are now calling a symposium to which they have extended Jeremy Hunt an invite- whether he will turn up or not remains to be seen. Seeing as how he hasn’t turned up to any of SEVEN crisis meetings in the last year at his OWN organisation I’m not holding my breath.

So junior doctors are left with few options. None of them good.

The first question is – do you accept the contract or not?

If doctors accept working under this contract, that still disadvantages women and LTFT workers and still is worryingly untested, then they must actively engage to make it work. This means forming local doctor forum, helping develop easy apps to exception report and challenging behaviour anywhere in the hospital that doesn’t meet the terms of this contract. If things go south, as these early rotas from obstetrics and gynaecology and emergency medicine anecdotally suggest, doctors must be vocal, and the BMA must back it’s members, although their powers may be severely limited.

If you don’t accept thev contract;

You essentially have few options. A lot will depend on how well organised doctors are from this point forward – with the BMA in full retreat this seems unlikely.

Leave training – the imposition of the new contract is for trainees – going out of programme, into locum work, into research, or even abroad will mean you continue working as a doctor, but you aren’t subject to the terms of the imposed contract. For those at the end of training, finishing up and then moving abroad is a sensible option.

Try to negotiate locally- whether individually or en masse doctors could offer to stay on the current contract, or organise a mass resignation against rota and contract conditions. Despite the bluster of NHS Providers it seems unlikely that hospitals will force a new, ‘cost-neutral’ contract at the expense of all their doctors. That is contingent of course on Health Education England, the training body of doctors, not imposing the contract by the back door and pulling funding for trainees who do not comply with the new contract.

Offer your own contract. This isn’t as mad as it sounds – making a counter offer is a standard employment arrangement in most industries, just unheard of in the NHS. A contract that doesn’t discriminate against women, pays for study and has fair and safe rota arrangements isn’t too much to ask. But it seems unlikely.

Bide your time. The contract is scheduled for review in 2018 – rumour has it Jeremy Hunt will be gone by then, and this may no longer be such a contentious political issue. With sufficient evidence of poor patient care and unsafe rotas, a renegotiation may be viable.

However, consider the context of the NHS. Over the past three years by every indicator the NHS has fallen into decline – waiting times, deficits, and now even hospital department closures, due to lack of staff. A new Autumn Statement might bring more money to the NHS, but having been through it’s most austere decade in it’s history, it’s even-odds whether there will even be an NHS at all come 2020.

For me, I left full-time training in August and have no plans to return. This contract dispute highlighted a multitude of problems with training to start with – but the utter contempt our NHS leaders, our government and their solicitors, and even some of our own seniors have held their trainees in appalls me. It has become a toxic environment for training and working. As a flexible worker I feel appreciated and needed, train and study when I need to, and most importantly, see and look after my family.

It’s up to the individual doctor what they do from here. If you can live with the contract, live with it. If you can’t, then find some way to find someplace you can. I fear too many will find that place outside of the NHS. With a collapsing union, a rejected judicial challenge, a toxic training environment and a complete lack of political will to shore up the health system, can you blame them?

Today Jeremy Hunt announced a return to imposition. He justified this despite an emphatic rejection of the contract by 58% of the referendum voters, to end the ‘impasse’ after three years and failing to agree a contract.
But the one question no one has answered for me is “what is the rush?”
Now the government would argue that they are keen to get on with their ‘seven day NHS plans’, despite the fact that the NHS is about to announce even greater spending cuts, George Osbourne has abandoned his surplus target for 2020, and record number of staff gaps for doctors and nurses are being recorded. Categorically, there is no plan for a seven day NHS, vis a vis there is no seven day NHS. What did we get instead? “Junior doctors are now a third cheaper”. There aren’t any more doctors- in fact many have now fled for Australia and Scotland. So no more doctors on weekends- just a third cheaper.
And whatever happened to the ‘weekend effect’- suddenly missing from what was core Hunt go-to doctrine? Well new evidence has dispelled this effect, making it more an artefact of how dodgy data was collected, and subsequently misrepresented. We’ve covered this before. Put simply- there’s no weekend effect for this contract to address.
And even if there were, junior doctors already work 7 days a week, no study ever linked junior doctor staffing to any ‘effect’ and the one study Jeremy likes to quote actually found 100% medical coverage across every day of the week. So this contract fight arose from a political position that has since crumbled away.
So what’s the rush? What’s the benefit of imposing a contract, which is legally fraught, onto a highly mobile professional body, highly
Motivated already to leave?

Now the government might turn back and say- well it’s been three years, and we still haven’t got anywhere.
Be that as it may- but why can’t it be three more years? If this was genuinely all about making patients safer, which it certainly doesn’t now, then why not take the time to actually achieve that?
Let me tell you about the contract. It is going to cover every NHS England hospital- so every patient in England will be affected.
The central Guardian role for protecting doctors from exhaustion, a key concern about this contract, has been rushed through in weeks- but practically no planning has been done.

Some hospitals have recruited this role for a mere 4 hours per week, looking after 1200 doctors. That’s just 12 seconds a week per trainee. Is that sensible or practical?

There is no plan for how human resource departments will be able to cope with the sudden ten-fold increase in complexity in the pay and rostering schedules, nor any plan for how educational supervisors, busy doctors in their own right, are now expected to take on a huge additional workload, another key part of safety completely mismanaged.

We don’t have an effective means of whistleblowing without getting sacked. Put simply- if I find a horrendous breach of patient safety neglected by my hospital management, and blow the whistle to protect patients, I can be sacked from my training post with impunity. Is that a good thing?

Lastly negotiations were still in progress to address the key discriminatory parts of the contract. As it stands it still will mean the careers of female medics are more difficult Than they are now. We are bleeding staff and resources in the NHS- what is the possible benefit of rushing a contract through that will lead to fewer doctors on shift, not more? Is that good for patients or staff or anyone at all?
You might argue that the BMA agreed this contract, and therefore it’s okay to impose it. Which is a rather paradoxical argument from just a few months ago when we were told the BMA were misleading us, now we should blindly follow?
Certain social media commentators ardently claim we are naive and childish. We are a group of people with an average of two university degrees each, twenty plus years of education, an average age of around 33, and many of us mothers and fathers ourselves.

We understand perfectly.
We understand the rush is a political expediency- politically this needs to be out of the news cycle, politically it needs to be off the front page, politically this needs to be out of the next election cycle. But I’m sorry, we aren’t creatures of politics.
We are doctors responsible for human lives; and we see a contract that will push more of our colleagues away from the bedside, stretch the doctors that remain, and leave no means to correct continued unsafe working. I’m not exaggerating when I say this contract imposition may hasten the end of the NHS, and has the very real potential to kill people. It’s not a decision we take lightly or naively. It’s also not a decision or negotiation to rush.

So Mr Hunt, I ask you again: what is the rush?
Work with us for a year to improve the safety mechanisms we have, to retain less than full time staff, to restore the morale and hope of us all. You keep telling us we are the ‘backbone of the NHS’. You are about to break it.
You don’t need a doctor to tell you that’s a rather fatal idea.
#listennotimposition
Juniordoctorblog.com

The decision to accept or reject these new terms and conditions is not only about the contract itself, but the context it sits in. In a two-part behemoth blog post juniordoctorblog looks first at the contract, and then the wider situation in the NHS.

There has been some movement between the March offer and the May offer on the safeguards for doctors working. The hours limits have been reduced, but realistically these are meaningless without a robust mechanism for enforcing them.

The new contract specifically removes ‘monitoring’, but more heavily involves the BMA/ local junior doctors in the process of ‘safeguarding’. This is a quick summary of the proposed new system for ‘breaches’ of hours.

The junior doctor reports a problem – this is called an ‘exception report’. This can be a problem about overworking on hours, or the post being inadequate training.

This ‘exception report’ goes to the junior doctors educational supervisor, with a copy to the guardian of safe working (see below) or to the director of medical education.

An initial meeting between the junior doctor and the educational supervisor occurs where the educational supervisor reviews the report and can remunerate the doctor, make changes to their rota or do nothing.

The junior can appeal up the chain – first to the guardian and DME and then to a panel – with the BMA or other sending a representative to sit on the panel.

The trust will collect data on rota gaps and report this to the GMC, HEE, and GDC. A copy should go to the junior doctors forum

The junior doctors forum will be formed by each DME and ‘advise’ the guardian on spending of funds produced from penalty fees paid to doctors who are overworked. The exact split of how much will be paid to the doctor and how much to the hospital is TBC

Here is a diagram from the BMA that outlines this process.

I have a number of issues with this system

The process from first reporting to sitting before a panel if an exception report is not dealt with properly is approximately 16.5 weeks at a maximum. That’s through every level of escalation. Seeing as how most placements last 4 months, and the doctor isn’t going to report on day one, this seems wholly unfit for purpose

The process puts a huge onus of responsibility on the educational supervisor, assuming powers that they certainly do not have currently, namely;

The power to create ‘learning opportunities’ in a work schedule. Imagine an ITU consultant ‘creating’ a clinic for a trainee to sit in, or an Oncology consultant ‘creating’ a procedures list.

The power to give time off in lieu or renumeration – mostly ES don’t work in dept or with rota managers, let alone HR – so how will this work?

The power to remove doctors from posts and initiate system-wide changes, especially as “The educational supervisor may be in a different department, and occasionally in a different organisation, to the trainee”

The final decision on an ‘overworked’ doctor is ‘final’ at the panel

‘Breaks’ – have to be taken at approx 30 minutes/5 hours or 2x 30 minutes in 9 hours. ‘Breaches’ related to missing breaks are to be ‘validated and found to be correct’ before any action will be taken. 1) Who covers during a break? Most shifts I’ve worked have been the bare minimum staff, so what is the arrangement to have a break? 2) Who is going to validate and find this correct? 3) Is it a ‘break’ when you are carrying a bleep?

Overnight rules regarding rest are welcome – if <5 hours rest or working continuously when on-call the doctor is ‘exempt’ from the next days work. But there is no provision in the contract for anyone to cover. How do you go home as the surgical registrar for example on a saturday after on-call if there is no surgical registrar covering?

The involvement of junior doctors in the running of their training is a good thing – but what is to stop them being sidelined in hospital? To my reading there are no mandated reporting of the guardian to the JD forum, no powers to stop a guardian appointee missing meetings and not engaging. Will this work in smaller trusts?

The entire removal of ‘hours monitoring’ is still the worst thing about this contract. But there may be a solution – see below.

There are many references to doctors being asked to make emergency cover arrangements, exceptional circumstances to cover rota gaps and accrual of ‘time in lieu’. Looking at the context (See linked post- Part 2) of the contract, I worry these are all clauses that will enable hospitals to stretch their workforces far farther than was previously safe. Despite the assurances that ‘breach’ penalties will be paid – the money now goes back to the hospital. This effectively removes any actual financial penalty to the hospital, and remains cheaper than hiring more substantive staff or hiring locums. In times of austerity I am concerned this will lead to hospitals relying on their juniors to plug gaps. But more on this in Part 2.

The guardian role. I have many issues with this;

The time commitment is ‘dependent on the size of the organisation’ but a singe guardian can still cover multiple trust sites. There needs to be a maximum number of trainees/guardian, the role has to be full time (previously advertised at 1-2 PA’s a week, equivalent to 4-8 hours work for a consultant), and must be completely independent from the board and HEE. Only independence is stipulated in the contract so far.

‘Work schedule reviews’ are triggered when the trainee believes the rota breaches the contract hours. How a guardian, who will be a senior consultant most likely in an unrelated specialty, will change rota’d hours and work commitments in another specialty seems practically very dubious.

Overall on safety I welcome the headway that has been made on what was a travesty of a contract in March, but I still think it doesn’t go nearly far enough, facing the crisis the NHS is heading towards.

Unfair?

On equality – the contract makes some important in-roads

The Guardian is seconded to ensure equality and diversity are respected, and that a ‘champion of flexible working’ is appointed within the educational faculty

HEE have promised to make a review into married couples and civil partnerships, and those with caring responsibilities, to make joint applications or transfer between regions more easily. This is supposed to happen next year. We will have to watch this very closely.

Transferring specialties for those with disabilities or care responsibilities will attract pay protection.

Pay protection until 2022 will mean those in registrar training now will not lose out, even if they take further time out e.g. for maternity or academia

Changing specialties may be further improved by a ‘mutual curriculum’ recognition programme to review next year

There are still issues here;

Non-resident on-call pay allowance is proportional to the amount of time spent in work. This means that two junior doctors are paid at different rates for the same work. That is not acceptable.

If you are non-resident but feel that going home is unsafe, the hospital will charge you for on-site accommodation, therefore you will be paying the hospital to work for them. At LTFT rates this will actually cost a significant sum per hour.

On pay

This is the most complicated part of the contract, and it’s complicated by the fact that we as a profession all work very different rotas, with different time commitments, on-call arrangements and duties, plus the point at which they are now in training. Johann has posted this cumulative comparison chart – both general and per specialties to review.

I still propose that everybody works out for themselves exactly their own earnings over their training lifetime – e.g. from F1 to ST8 or whichever, on both the old rates and the proposed contract. Remember to exclude NI (now 12%), pension pay (which is removed from your basic ONLY), and tax.

Here is a complex calculation I did – based on a medical rota of 40% 1B banding;

As you can see the lifetime take-home pay for a 40% 1B banding on the old rota, compared to a 1 in 6 weekends, 1 in 6 nights rota (4 nights every 6 weeks at 12/hr per night), is a very slight pay rise, over 10 years of training, of around £600/year. However on a 50% 1A banded rota, roughly 1 in 4 weekends, 1 in 4 nights rota (again 4 nights, 12hrs/shift, every 4 weeks e.g. typical ICU) it’s a slight pay increase, £300 per year take home pay. So while the ‘basic payrise’ disappears in take home pay, it does increase your pension however, I have yet to calculate exactly by how much. Whether or not this is acceptable to you is a personal opinion.

(Please post your individual calculations in the comments below with the conditions and your working, so we can get a collective sense of how everyone will be affected. Remember your vote is for yourself, but also for your colleagues.)

The real issue here is how out-of-hours work scales – the pay difference between a 1 in 4 weekends, 1 in 4 nights vs a 1 in 2 weekends, 1 in 4 nights, over your lifetime is about £500/yr. As in for working twice the weekends you were previously (and for work the definition is any hour worked on the weekend), you will be paid roughly an extra £60/month. That won’t really cover twice as much childcare for example. As pointed out previously, ‘acute’ specialties will lose out the most.

With further below inflation pay rises we stand to continue receiving this stealth pay cuts: 1%, 0.9% and 0.8% over the next three years, with inflation predicted to rise between 1-2.5% by 2020.

This doesn’t take into account non-resident on-call or flexible pay premia pay.

On NROC I see two main issues.

The ‘prospective’ average estimate is not going to actually work – shifts will vary wildly between having to be ‘at work’ and not, depending on several factors, some of them dependent on the individual doctor. The contract is very specific; ‘work’ is any clinical work, including telephone calls.

I can imagine pressures on judgement for doctors that preferred to ‘go in’, if they are outliers in a rota where most people don’t. This creates a mechanism for monetary considerations in clinical judgement. I find this unacceptable.

Again, the 8% on-call allowance is acceptable, as long as work done on-call is paid for at the prevailing rate, and it is still safe to regularly work the next day. This will take exceptional vigilance on behalf of individual trainees- more on that below. Again this will be overseen by educational supervisors and guardians of unsafe working.

On flexible pay premia; for academics this is good, and for hard-to-fill specialties this may be good, although I imagine the amounts spread over training and subject to tax would make very little difference to take-home pay on a monthly basis, especially in hyper acute specialties already losing out on unsocial hours like A&E.

Pay protection is rubbish. Please do not rely on this. The ‘cash floor’ is created by your earnings plus allowances on 31 October 2015 or 2 August 2016. This does not take into account the rise in salary you would be due if you weren’t on the new contract, and only protects your basic. Allowances for weekend and unsocial hours are calculated on your new basic, in the same way.

Locum work: this is going to be a disaster. The assumption is the majority of us are in training and doing sneaky extortionate locum work through agencies. Forcing us to work through a staff-bank for shifts isn’t going to change a thing. Why?

1) Most full-time trainees cannot safely do agency locum work on top of their existing training commitments. I have probably done maybe 5 locum shifts in my career.

2) Most agency locum doctors are not in training- therefore unencumbered by these clauses anyway

3) Even if the odd shift we work on top of training was covered as an NHS bank instead of as agency bank, it would still leave the majority unfilled. Usually this worsens cover for substantive trainees, making conditions harder and dangerous.

4) It’s also unnecessarily punitive, and generally annoys people to think that a contract can monopolise their personal time as well as the time they spend at work.

5) I suspect this will actually diminish the part-time locum market, making posts harder to fill.

Pay for work done. Through the guardian system you will need to be ‘authorised’ for additional hours, either before, during or sometimes after the hours worked, if you want to be paid for them. This does not reflect our usual working practices, and the contracts refers us to our ‘manager’. I have never really known who my ‘manager’ is, and as for staying late it’s always been for emergencies, when seeking authorization is not practical or safe. Again any monetary concern interfering with clinical practice is unacceptable.

There might be ways to sort this – but it would need to have a clearly defined ‘manager’ who is reachable 24/7, and routine acceptance of ‘after-action’ authorisations for additional hours. I can already foresee this falling apart instantly.

Overall on pay I think most people will see no difference in pay, if they stay on current rotas. However, with the proposed rotas yet to be seen, you will see a substantial drop in pay for increased unsocial hours that you would’ve previously received. If your rota goes from 1 in 4, to 1 in 2 weekends, you will be paid pretty much the same. I’m happy to be corrected on this by anyone who sees flaws here – this will need to be a collaborative effort to try to ascertain the impact the contract will have.

What else?

There is a clause in the contract saying HEE actions are subject to reporting ‘without detriment’ to the individual junior doctor. This is regards to the Chris Day case – I have spoken with Chris and he doesn’t trust a contract clause like this to actually stand up in law. It needs a law change to back it, to protect trainees like Chris.

Leave is only allowed during ‘non-enhanced hours’ work – which now means only between 0700-2100 and no weekends. This isn’t dissimilar to current arrangements, but if rotas increase out of hours unsocial work then actually swapping to arrange leave will be difficult.

Summary

Overall I think it comes down to trust. Do you trust your hospital and your bosses to be able to implement this contract without compromising your safe working, and to listen to your concerns if it does? Do you trust your hospital and it’s managers to honour its agreement on pay for work done, and to not create rotas which are punitive and cover a lot of excess unsocial hours? Do you trust your hospital and your health secretary to listen to your concerns when the contract is reviewed in March 2018?

Think on this carefully. Then think on your vote; remember the ‘referendum’ will only guide the JDC, so if it’s close it will be far more difficult than if it is clear-cut.

This won’t be a simple vote on whether you find this contract acceptable or not. Both options will require ongoing action to ensure that the terms and conditions don’t simply slide back without our input.

If you vote yes;

We will need a system to accurately monitor hours, to ensure not only that you are paid for work as you are supposed to be, but that hospitals are running safely, and not overstretching doctors. Without formal hours monitoring we will need to provide hard evidence, that is easy to record and easy to generate, that we need more doctors.

We will need to take an active part in our hospitals, ensuring that the LNC is a visible entity, with real power and real support. We must be prepared to escalate and see through proceedings about breaches and training

We must ask for reassurances that educational supervisors will evolve into the super-entities that this contract requires -that they will have power to actually do what the contract suggests they can do

We will have to be vigilant that the contract is implemented respectfully and honestly, and report incidences where it is not – to both the local LNC and the BMA and wider community.

We must no longer isolate ourselves if we hope to survive as a profession – don’t leave that Facebook forum even if you really want to.

If you vote No;

We must think about what comes next – what do you want to see, and how do you want it to be achieved?

Are you prepared to re-escalate strikes? To resign?

We must recognise that a close vote will mean the government will accept the contract on behalf of the minority ‘Yes’. They want this to go away, and don’t wish to concede any further.

We must recognise the ‘context’ of this contract. Will a No vote lead to benefits in the long-term? What would the junior doctor workforce look like in the future?

I am writing to you, because, like myself, you are a normal human being.

You, like me, wake up in the morning and sleep at night, eat meals, sometimes with loved ones, sometimes alone. We are alike in our requirement for other people, for happiness, for security, for food, for warmth, for shelter.
You may have children, you may have brothers or sisters. You have, or had, parents, and perhaps were lucky enough to know your grandparents.
You may have noticed that many health professionals are becoming uncharacteristically vocal. You may have thought them self-serving, morally bankrupt individuals, upset over their own pay packets.
I would like to explain to you, from one normal human being to another, what is going on.
I am a doctor. I decided to be a doctor before I really knew what decisions were, and can never remember wanting to do anything else. Once I knew how, I found the path, and worked my arse off. Six years, in secondary school, studying. Two years, in college, studying. I took four A-levels, I had 25% less free time than my friends, and when they were out, doing whatever they wanted, I was not. I was studying. Another six years at medical school, studying, and sometimes working to pay for the studying. The last three years of medical school I worked harder than I ever had, and the same hours as a full-time professional, sometimes way more. It even made me sick- in my final year I developed acute gastrointestinal bleeding. But, becoming a doctor was all that meant anything to me. So, I took my top grades and turned them in, in return I got fourteen years hard graft, and £50,000 worth of debt. [2]
Why is this important? Because, from the very beginning, I knew about sacrifices. As thousands of my colleagues have, as millions before me have, and millions will. I knew about sacrifice when I worked for a year before university, so I could afford the rent, when I missed my first family Christmas to work as a warden in student halls, so I could afford to stay at medical school. I knew about sacrifice when I missed nearly every other Christmas since, working, or sometimes studying. I knew about sacrifice when I’ve missed my friends weddings, my nieces and nephews birthdays, when everyone I knew was travelling, and I was studying, or working. Being a doctor, and it’s inherent position in society and in the hearts of the public, is irrevocably tied to sacrifice- it’s the dedication it takes to become, and to stay, a doctor, that by definition requires sacrifices to time, to personal satisfaction. All over the country right now, doctors and nurses, physiotherapists and occupational therapists, radiographers and ward clerks and all the other medical professionals are sacrificing their lives, minute by minute, to try to give you or your loved ones minutes, hours, days or years more. So, when, as a normal person, someone tells you doctors don’t understand ‘vocation’, you know now- it is beat into us before we even get through the door.
But, as a normal person, of course you understand why doctors would defend the NHS, would fight to protect it, and so vociferously attack it’s detractors. They have a vested interest, they want to keep their cushy salaries and great jobs, and the NHS is great for that.
Let me tell you straight: if I didn’t care about you, or my patients, I would be out there campaigning to close the NHS right now. I would make more money in the private sector in a day than I would in two weeks of NHS work. I could also take my UK Medical degree, one of the most respected qualifications anywhere in the world, and go and earn 50-200% more in the US, Australia, New Zealand [3]. In the private sector, if I stayed after 5pm to look after you, the next thing you see after my smiling face as you exit the hospital, will be the bill on the doormat; ‘overtime’, ‘time in lieu’, ‘additional hours rates’ aplenty.
But, I, like you, have a family. I went to state school, and worked and grafted to pay for my six years at University. Without the NHS my grandmother would have gone blind, my father would have had several heart attacks, my mother would have died. I might have died. A private system would’ve bankrupted them, ended their hopes for a better future in order to pay to survive. I, like you, would do anything for the ones I love, and that is why I campaign to protect and improve the NHS. And that is why, when 5pm comes and goes, as does 6pm, 7pm and all the other hours in between, I, and every colleague I have ever worked with, stays for their sick patient. Because, one day, somewhere, for someone else, that patient will be their mum, or dad, wife or husband, son or daughter.
We have had, and always have had, the extraordinary privilege of one of the greatest healthcare systems, pound-for-pound, in the world. The reasons for it’s great outcomes and low cost are debatable. But there are some reasons we never mention. This country has a medical school system of international renown, whose doctors, for the most part, qualify and stay exclusively working within the NHS. The staff of the NHS gives untold free hours to the profession; when I was a first-year junior doctor, I calculated I worked one day at work for £4.10 an hour. I used to get paid more at Tescos. But a very sick patient needed a lot of complex care, and so I stayed, and helped, and he survived: as millions of patients have since 1948. [4]
The moves of the current government against the medical profession are calculated: to deride working conditions, salaries, hours and deplete hospital resources, until a normal person, like myself, buckles under the social, financial and emotional cost. At that point, a sea-change of new, private hospitals will open, and we will go and work there. And our lives will be pretty much the same- different bosses, the same bureaucracy and probably better pay. But our lives, as normal people, will not. You will still pay taxes, a stripped-down NHS will persist, for no frills, emergency care only, but not for all the other healthcare needs of a 21st century population: you will need private healthcare. And that healthcare insurance will cost you hundreds of pounds a year, if not a month. And if you don’t have insurance, you will spend thousands of pounds on the simplest, quickest procedure [5]. And the NHS won’t be there for my family, or the families of normal people across the country.

So, I want this to reach as many normal people as it can. If you don’t act now, it will be too late. It might already be too late.
We care deeply because we can see the great good the NHS does, every single day. And I care because, like you, I care about the ones I love.
Where can you start?
Here might be a good place:

Www.crowdjustice.co.uk/case/NHS

We are taking the government to court, to show us they aren’t gambling the future of the health service away on an unmodelled and unsafe contract.

[2] Medical students studying now can now expect to pay £9000 pay a year as of 2015 for six years for most courses: that is £54,000. Most will require a student loan to pay living expenses for a full time course, at a further £5000 a year that totals £79,000 for six years study. Maintenance grants for the poorest students have been scrapped, adding an additional £10,000 debt as a minimum.

[3] Starting pay for any consultant in the UK : £75, 249. In the US: £111,799.80 for internal medicine, £183,152.91 for a radiologist. ($/GBP rate correct at time of writing). In Australia: a basic salary of £78,000 for internal medicine consultants, BUT this is for a 38 hour working week. Average overtime and up-scale pay between £92,526.97- £244,366.10. Same with New Zealand for a 40-hour week, after average overtime and up-scale up to £128,039.69.
UK data: http://bma.org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/consultants-england